The Integration of Precision Medicine into a Medical School Curriculum By C. William Heise, MD, Steven C Curry, MD, Paul R Standley, PhD, Kenneth S Ramos, MD, PhD, Kurt E Gustin, PhD, and 50 Raymond L. Woosley, MD, PhD The JournalMedicine of Precision Journal of Precision Medicine | Volume 7 | Issue 2 | June 2021 thejournalofprecisionmedicine.com 51 Introduction Solutions to these problems exist! And while directors identified where precision medicine was The University of Arizona College of Medicine the vast quantity of relevant clinical data and new currently taught in their block and completed a – Phoenix (COM-P) is a separately accredited genomic information may be very difficult for a comprehensive query of the curriculum topics. medical school within the University of Arizona physician to recall and utilize in the clinical setting, Most blocks included material which briefly Health Sciences with a unique MD precision a computerized decision support system, built mentioned concepts related to genomic or medicine curriculum tailored to the Phoenix seamlessly into the electronic medical record and precision medicine. These materials, however, The JournalMedicine of Precision community’s health needs and opportunities.* workflow, provides a solution. The COM-P is in a were nebulous and thereby lacked a unified There are several curricular themes integrated unique position with its primary clinical partner, goal; furthermore, this information was vertically and horizontally across all four years. Banner Health, to utilize a large healthcare system commonly presented to medical students as For clinical practice, a major element of precision with an advanced electronic health record for “for the future.” A small amount of teaching time medicine is using population clinical data to aid education, research, and patient care in precision was dedicated to interdisciplinary patient care in a physician in ensuring that the patient gets an medicine.5 In addition, the COM-P is actively genomic medicine, including interdisciplinary effective treatment at the right dose at the right working to integrate decision support and precision education by genetic counsellors, but this has time with minimum ill consequences based on that medicine into both undergraduate and graduate not always been perceived as useful by the patient’s individual clinical profile. Despite these medical education. students. A recent national survey suggested that advances and the general acceptance of The assimilation of precision medicine students lack insight into the possibility of careers data-informed decisions by patients,1 adoption by into the curriculum requires a paradigm shift in medical genetics, biomedical informatics, or clinicians has been surprisingly slow.2 To overcome similar to that which led to adopting and medical toxicology.6 any barriers in translating genetic laboratory adapting to evidence-based medicine 20 years Evaluation of the initial clinical curriculum test results into actionable prescribing decisions, ago. While improvements in individualized revealed that little teaching or role modeling the Clinical Pharmacogenetics Implementation efforts toward disease prevention, medication of precision medicine was available during the Consortium (CPIC, https://cpicpgx.org/) was effectiveness, and medication safety were deemed clinical learning years. Instruction that was done formed to evaluate evidence and recommend more likely, the precision medicine paradigm had in this discipline was limited to a few individual which drug use could be supported by individual to be developed, implemented and tested. preceptors, rather than any concerted efforts on genetic testing. In addition, they identified a focused, longitudinally integrated teaching and number of impediments to adoption, including Curriculum Prior to the Launch mentoring that would inculcate this approach limitations in the electronic health record, cognitive of Precision Medicine Theme in the students. National surveys indicate many barriers, lack of incentive to prevent adverse In order to establish a baseline and evaluate preceptors may not feel comfortable integrating events, availability of preemptive testing, and the inclusion of precision medicine in the and teaching precision medicine.7 No specific privacy/legal concerns.3,4 pre-clerkship curriculum, pre-clerkship block elective rotation is yet available. @journprecmed Journal of Precision Medicine | Volume 7 | Issue 2 | June 2021 engaging and well-designed in course evaluations. In fact, these sessions received an average score of 4.9/5 in student evaluations in the first two years. Student comments included: ■ “Awesome and engaging session and I loved learning about this!” ■ “This session allowed us to interact directly with the resources that help clinicians answer pharmacogenetics questions,” and ■ “It is very relevant to consider how different genetic profiles affect drug activity.” During the clinical rotations in the curriculum, a series of intersession learning studios that are immediately applicable to the content of the clinical rotations has been developed. A short overview document will be created to provide each clinical rotation director recommendations for how best to teach precision medicine that 52 is specific to their area of expertise. An elective rotation will begin during the next academic year, starting in the Section for Precision and Genomic Medicine in the Department of Medical Toxicology at our primary clinical partner, Banner – University Medical Center Phoenix. In addition, we plan to add a rotation to our local VA hospital in conjunction with the clinical PHASER (Pharmacogenomic Testing for Veterans) and research Million Veterans’ Program (see https://www.cancer.va.gov/phaser.asp). Each year, the Precision Medicine Theme provides a report to our institution’s curriculum The JournalMedicine of Precision committee for review and comment from Figure 1: Objectives of the COM-P Precision Medicine Theme scientists, physicians and staff. At this time the theme is updated to include advancing science, new material, added clinical adaptations and Intervention of continuing medical education (CME) offerings and feedback. Sessions may be added and have been Precision Medicine Theme career development in these sessions was evaluated entirely revised. In order to facilitate the teaching of precision and identified as valuable by faculty. At our affiliated graduate medical education medicine, faculty who were interested in the Revision of the pre-clerkship curriculum did training sites, presentations review current integration of precision medicine into their clinical not add class hours but involved revision of relevant recommendations for implementing practice, teaching, and research were identified and current teaching sessions to highlights concepts precision medicine and explore opportunities for encouraged; those faculty members who expressed of precision diagnostics and pharmacogenetics collaboration in research. One major goal will interest were invited to a series of workshops that (see steps to revise the curriculum for our program be to familiarize trainees with the best available focused on genomic medicine topics relevant to are enumerated in Figure 1). We employed both educational resources for learning consensus the medical practice. informal discussion with each block director and practice guidelines and results of up-to-date Several specialty areas with the highest level of a formal audit of the pre-clerkship curriculum outcomes research. expressed interest were targeted. These included for relevant sessions and faculty development the areas of toxicology, neuro-psychiatry, oncology, for session leaders. The COM-P has set a goal Discussion cardiovascular health, infectious disease and of increasing the number of “flipped classroom” The goal of the Precision Medicine theme was transplantation medicine. We highlighted how or active learning sessions. Thus, the changes integration into the curriculum and ensuring every precision medicine can combine with biomedical implemented included the development of physician trained at the COM-P is proficient in informatics for healthcare delivery and discovery independent learning modules, simulation sessions, the use of pharmacogenomic data and advanced research. These faculty workshops cultivated and learning studios with active participation. clinical decision support systems. We want to collaborations among faculty to initiate research Interdisciplinary education in this area, in particular prepare physicians to effectively integrate future and add didactic methods in teaching precision genetics counsellors and pharmacists, was key. advancements into their patients’ care as well as medicine. The importance of offering meaningful Students noted this information was helpful, educate and guide patients. JOPM Journal of Precision Medicine | Volume 7 | Issue 2 | June 2021 thejournalofprecisionmedicine.com Kenneth S. Ramos, Paul R Standley, PhD Raymond L. Woosley, MD, PhD MD, PhD I earned my doctoral degree in Kenneth S. Ramos, M.D., medical physiology at Wayne Raymond L. Woosley, M.D., Ph.D., is the Alkek Chair of State University School of Ph.D. is Professor of Medicine Medical Genetics at Texas Medicine in Detroit, Michigan and Biomedical Informatics in the A&M University Institute of then completed a post-doctoral University of Arizona (UA) College Biosciences and Technology. fellowship in the Division of of Medicine in Phoenix (COM-P), He also serves